Article Source: msnbc.com
from:msnbc.comPsychiatry has lost its soul. That's how grimly Dr. Daniel Carlat, a psychiatrist in private practice outside of Boston, characterizes the state of his profession.
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If Carlat wants to know how his patient is doing on their meds prescribed by him and that patient is also going to a psychologist, why isnt' the Dr. and the therapist getting together and discussing the patients issues? Yes, the patient has to consent for this to happen, big deal, just get to it. Excuses all around, pathetic.
It is truly alarming how much psychiatry and even clinical psychology have not only changed, but diverged from both European and American "best practices."
1) SSRI's, the widely prescribed anti-depressants, are among the most physically addictive substances known to medicine. Far more so that heroin or cocaine or other illegal drugs. Yet this fact seems little-known to the public.
2) SSRI's are very spotty in how well they work in individuals. Some SSRI's work in some people and others in others. When they are truly appropriate, patients are often required to switch drugs several times to find the "right" one. The addictive nature of SSRI's, combined with the already supposedly existing depression, can create a life-threatening situation.
3) Most SSRI's are prescribed by family physicians with very little specific training in the use of psychotropic drugs and little to no followup.
4) Best practices require that SSRI's be accompanied by other forms of therapy to be truly effective. Best practices also require very frequent monitoring during periods of initial use, switching of drugs, or discontinuation. There is no clinical indication that anyone is helped by SSRI's with no adjunct therapy.
5) SSRI's work completely differently (in some case by very different mechanisms) on pre-adolescents, adolescents, pre-adults (19-25), adults, and the elderly. Dosages of SSRI's are very sensitive to sex, weight, and activity levels among other factors.
6) Much of the diagnosed "depression" is just normal grieving or reactions to life's normal ups and downs or to seasonal variations in light. SSRI's actually can impede a person's ability to "work through" situations such as loss of a loved one, loss of a job, post-partum blues, or just normal "bad days."
7) Failure to follow best practices can have deadly consequences.
I had a 15-year-old cousin who had been inattentive to his studies and was in danger of flunking a couple of classes. In addition, he had smoke some pot and had been selected for a random drug test. Because of these situations, he began "moping around the house." A family physician diagnosed it as depression, prescribed SSRI's, and did no followup or referral for adjunct therapy. Three weeks after starting the SSRI's, this nice-looking, well-mannered, good-natured teenager put a shotgun in hos mouth and killed himself.
The drug company and the physician's malpractice insurance company rushed to get the family to sign off on settlement for an undisclosed amount of money that forbade the family to seek any criminal, civil, or professional disciplinary action.
These drugs do have a place in treatment, but are vastly over- and inappropriately prescribed. They are ideal profit-makers for the drug industry because they are addictive and expensive. There is a huge amount of negative research that has been suppressed or disregarded by the FDA regarding the proper use of SSRI's.
The for-profit medical insurance industry also shares some blame. They will pay for pills, but put strict limits on adjunct therapy if they pay for it at all. Many "psychiatric" conditions have taken years to become a problem and often take just as long to resolve. There is no psychotropic drug that is a cure-all, feel-good solution to any known psychiatric condition.
Chris,
I am sorry to hear about your young cousin's suicide, but I think this is more of a testament to the seriousness of depression than the danger of SSRI's. You have your facts wrong on many accounts, and I fear it might lead people to avoid treatment for depression. When a warning label was put on antidepressants a few years ago, it frightened people into avoiding treatment and suicide rates WENT UP because people were NOT taking medication to treat their dcepression. Many of the "facts" you enumerate are just plain wrong.
1) SSRI's are not addictive. There can be side-effects when they are abruptly discontinued, but this is different from addiction.
2) see #1
3) True
4) False. medications and psychotherapy are more effective when used together, but both can be effective on their own.
5)False. SSRI's have the same mechanism in all patients with minor variations in metabolism which can minimally affect dosage.
6) False. Show me the evidence that SSRI's impede normal grief.
7) True. Patients who are early in their treatment for depression are at higher risk of suicide and should be monitored closely, regardless of the type of treatment they are getting.
Your comments are full of over-generalizations that could discourage people from getting treatment, and could lead to more people committing suicide, so I felt the need to respond.
As a very busy psychiatric nurse practitioner, I believe we as a profession can help fill the void of prescribers. We have the medical/nursing background needed to prescribe meds to people that not only have psychiatric issues but multiple medical/health issues as well---with multiple drug-drug interactions to be aware of. As a provider---I TALK with the therapist seeing my patient on a regular basis. I also TALK with my patients spending every minute I can out of 20-30 minutes discussing how they are doing. Many of my patients tell me that they are used to a psychiatrist just writing scripts and not really asking how they are doing--
This is my opinion, based on being involuntarily hospitalized at an early age, comparing how things were run then (some 42 years ago), and seeing how things are run today.
First of all, the entire GAME--and it is a GAME no matter what all the players IN IT may think of themselves---is to go for as many and as much insurance MONEY as humanly possible. The patient comes DEAD LAST in that equation. PERIOD. The GAME is run on the ENTIRE PREMISE that the public must be protected from individuals who may pose a danger to other people--and this bias, mostly wholly invented, is milked by the media and Psychiatry to its fullest, with assent from courts and the general public due to failure to understand the bogus nature of this entire system.
Secondly, human rights violations occur all the time in that industry whilst folks are going for the MONEY--which include denial of due process, failure to really examine patients to see if they are a danger to themselves or others(which is what the state laws all provide), and the continuation of the mystique that Psychiatry is really doing anything of any VALUE in all that by somehow protecting the public--which it pays no attention to doing anyway. It is all to CREATE as many mental "illnesses" as humanly possible through the ever-expanding DSM books with ever-increasing entries therein---prescribe drugs that ALLEGEDLY treat these (and there is NO EVIDENCE WHATSOEVER that these actually accomplish that)--and milk and bilk insurance and patients for all they have in the process. In fact, a disproportionate amount of the acknowledged overexpensiveness of the American Health System is attributable to Psychiatry which provides 20% of the billing and much less of the percentage of overall care due to all specialities. Any fool can see that there is something wrong with this equation. And that "something" is very definitely the coercive nature of hospitals running Psych Units and Psychiatrists and the entire mental health system being "IN BED WITH THE HOSPITAL SYSTEM." Human rights be damned, the federal Constitution be damned, but the Almighty Dollar---well now---THAT'S a MUCH DIFFERENT STORY!!
There is however a "way out of this mess"--which is if every patient who experienced the baloney found in the mental health system were to file under False Claims Act on both the state and federal levels, some real "parity" would occur toward steering these greedy bastards in the profession of Psychiatry and all the so-called allied health practitioners as well into something that not only respects people as having any rights--but also protects taxpayers from the regular and usual fraud that is simply built into today's system.
Finally, nurse practitioner darling--it ain't about "talking" about anything, particularly in a hospital setting. It is about securing human rights for the patient there once there because there simply ain't any of those in that setting, and certainly in an outpatient setting drugs continue to be overprescribed, overworshipped, and underappreciated as the purveyers of premature death in such a system that they are--all for the benefit of shareholders in the drug companies. Oh--and "how they are doing" is irrelevant to any REAL attention paid to such issues--it is only through long therapy that anyone could possibly change, if that is the issue--and that takes more than a drug and hospital culture in the system to accomplish, a system that is hellbent on continuing its coercive nature because that is where the MONEY is, sister....and you happen to be a part of that, whether you enjoy that self-concept or not!!
Another problem with psychiatry is that many of these psychiatrists give the patients 15 minutes and decide that they know enough about the situation to give the patients all of these meds. There is a psychiatrist in this town that is known to do that, then he fobs his patients off to one of the LPC's that work under him (and can't prescribe meds) for therapy. So, the patients are basically paying two bills--one for the 15 minutes with the psychiatrist and one for the hour with the LPC. And, naturally, the psychiatrist costs more.
The problem I have had with the tendency to medicate is that it's almost a band-aid. If someone is depressed due to a bad family situation, just medicating them will do nothing to stop the root of the problem. Same for someone with PTSD just getting anti-anxiety pills. Now, there are people with disorders like bipolar and schizophrenia that pretty much require meds, but a lot of psychiatrists just medicate and be done.
Primary care physicians that admit they know nothing about psychology/psychiatry are also getting on to this game too, but that's another story.
When I lost my right foot in Afganistan I was left or developed PTSD. While as an inpatient at Reed AMC and Ft. Hood there were just not enough psychiatrists to handle all of the cases. I had scheduled two appts. with Major Hasan, MC and he failed to show up for both of them. Today, and internist writes all of my medications from pain meds, high blood pressure drugs,and drugs for the PTSD and anxiety. I do go to group therapy weekly and see a psychologist once a month.
I have learned that there are so many Americans with depression and anxiety that there are just not enough psychiatrists to see them. Also many people do not have adequate medical insurance or can even get the time off work to see a psychiatrist or a psychologist. The drugs that I take for PTSD are Citalopram, Clonidine, and two Valium pills a day as the valium relaxes muscles and eliminated the need for Soma.
The PTSD/GAD/ and Depression drugs that are available today are good. I am retired form the Army and get V.A. Disability and Social Security and work out daily to improve my psysical condition which is pretty good. If I am not wrong, the psychiatrists see people that are inpatients for the most part.
Hello Kitty,
I know that I will have severe anxiety for the rest of my life but it is controlled very well. I don't see how seeing a psychiatrist every week one on one will help me. However, the group therapy and the once a month visits one on one help. I started with Prozac and then switched to another generic called citalopram.
I have become aware that many Americans that were not in the Army or lost a limb suffer from anxiety and depression. At least I am very happy that I am not depressed on top of everything else.
Sometimes people just need the prozac or celexa that introduces more serotanin to the brain to make them feel better. I hear that not many docs go into psychiatry as there is not that much potential to earn the big fees.
Our country has changed a lot and continues to change.
Hello Kitty: Narrow minded, much? My brother was in the Marines and served in every human cesspoil within the last 20 years: Bosnia, Somalia, Iraq, etc.... You get the picture. In Somalia, he crawled through dead bodies that were bloated and stinking so badly, he had to pull his shirt over his head and puke into it. He developed PTSD after 20 years of this type of duty and can barely leave the house to go to work as a school teacher. He doesn't go to the mall, the store, the movies - not anywhere - because his nerves are so shot he can't take the stress. He takes anti-anxiety medicine because he wakes up at night screaming. Maybe you should know what the hell you're talking about before you shoot your mouth off. Just because you don't need medication, doesn't mean other people don't take comfort with it.
Psychiatry is only one victim of a medical system that exorbitantly reimburses procedures and high tech tests while neglecting primary care, prevention, and cognitive services. Only 10% of medical students are entering primary care fields. At that rate, by the time the baby boomers need their services, there will be hardly any primary care physicians left.
The medications that have revolutionized psychiatry have not played as big a role in corrupting psychiatry as the good doctor would have us believe. A good psychiatrist should have time for both, but who is going to pay? Not private insurance, not Medicare. We have a name for doctors who make a living off touting pharmaceuticals: Drug Whores. I opine that Dr. Carlat lost his soul when he became one. The American people lost theirs when they allowed insurance companies to dominate a profession that was once noble. People afraid of government death panels? Insurance companies already have them.
How many of you docs go out and have a big lunch and a little golf with drug company representatives? You aren't doctors anymore just pushers.
I have long been alarmed at the rate and willingness to just prescribe a pill. We have all had issues, problems and ups & downs in our lives, and I have found that dealing with those is often the best remedy. Nobody is allowed to cope anymore it seems-. We seem to be taught that we are incapable and we need professional help and a plethora of meds to deal with anything. How I wonder, has humanity made it through the eons? I have never denied that there are people who are truly mentally ill, and truly, clinically depressed. But these are the extreme cases. Intro to Psychology 101...do not rush to diagnose, mental illness is an extreme in behavior.
The gentleman with the Ambien? Many Dr's would then prescribe Provigil to keep him awake. Do you have any idea how many people out there are walking around on multiple meds? Meds for depression, for anxiety, to go to sleep to wake up? A little distracted? Prescribe ADD meds...and on & on.
Why drugs in all circumstances? Many people in third world environments recover fully and are not condemned to a miserable life of drugs and all the devastating effects they have. Yes time and proper environment heal!
Don't lament the "good old days" of psychiatry - there weren't any. Before SSRIs, patients with depression caused by an inbalance in their brain chemistry were psycho-analyzed and counseled to death, but it never worked because deep and meaningful discussion cannot remedy a seritonin imbalance any more than it can reduce blood sugar in a diabetic. The change in psychiatry today represents a transition from useless voodoo to a more effective approach based on science. Not all patients who suffer from depression or other mental ailments can be helped with pharmacuticals but those who can are unlikely to be helped very significantly by counseling sessions.
Ah yes, the "good ole days" of psychiatry. You could be so lucky to be psychoanalyzed and counseled to death. Those were the wonderful times of electroshock therapy in its infancy (awake the whole time, just seizing away) for bipolar disorder and schizophrenia and insulin therapy for depression. If you were not coming along on those treatments, then you could have the icepick lobotomy through the eyelids like my great uncle had back in the 50's. Scary sh!t, huh.
Here is the reality, it is significantly worse than described in the article. I am married to a psychiatrist and my brother is one also on the west coast. Here is the reality of medicine and psychiatry today:
You get 15 min because that is what the insurance will pay for. 6-8 hours of your psychiatrist's day is spent seeing the patient, the balance of the day - often exceeding another 4-6 hours, is spent documenting the visit in the chart, arguing with insurance compaines on coverage or drugs in what is called a doc-to-doc review, writing letters or filling out forms that they do not receive compensation for but are required by employers for the patient to keep their job and hence their insurance coverage and, for fun, every 5 or 6 days, you are on overnight call for emergencies - essentially a 36 hour shift potentially.
You are required to see at least 25+ patients a day (my wife worked for one practice that required more than 30) to make your "RVU" target and must exceed that if you want to make any bonus. Patient contact by phone, e-mail or any other method does not count toward RVU credit or compensation. Court apperances on behalf of the patient are not compensated for the most part. If you are called at nigth by the nurse on duty, you are not compensated.
You are no longer in any way, shape or form, the team leader or effectively "in charge" of a patients treatment. You are, however, 100% liable if anything goes wrong and are responsible for all other health care providers if anything bad happens - even if the patient isn't in the hospital or is being treated by a therapist.
Why only drugs? Here is why. The psychiatrist practicing under the current system is the equivalent of a master carpenter who has to repair a very delicate table but may only use a 5 lb hammer to do so. The psychiatrist is limited to his or her perscription pad as the ONLY tool to treat a patient. They can't do therapy and don't have much time to do anything else.
Additionally, virtually all aspects of a psychiatric practice are controlled by MBAs who do not understand proper medical practice and are more concerned with the correct billing code than with patient outcome. If you don't believe there is corprate practice of medicine (an illegal practice) you probably need to look in the mirror and question if you need drug or alcohol counseling your self. It is 100% the corporate practice of medicine.
As to the comment concerning golf and a big lunch, both are now illegal under Federal Law. My brother used to do this (my wife believed it to be a conflict of interest) to defray his medical education which left him 120K in debt. The practice of paying phsicians was greatly curtailed a few years back because of the drug companies practices and with 10 - 12 hour days routine, where would you get the time?
Several psychiatrists in our area (Baltimore) have simply dropped out of the system and now treat only the "worried well." They accept Visa/MC and Amex. They do not accept certain categories of diagnosis in their practices like Borderline Personality Disorder. One other benefit is that none of your information is reported to the big database in the sky so there is less a chance of you being denied a job or insurance or pay higher premimums for life or health coverage.
By comparison, I am an attorney and a simple letter will run you about $150, a phone call is 15 min of my time and I'd be happy to work on your case for $450 an hour. If you don't like those prices, go someplace else. I don't take insurance. Does anyone seriously think the legal profession would put up with a rule that limits payment for a Will or Power of Attorney to no more than a 15 min meeting with an attorney and a cost of no more than $75?
Wake up. The insurance companies, drug companies, lawyers (yes, we share in the blame) and MBAs have effectively stripped all power from physicians to either negotiate price or treatment options. The myth is that most individuals still believe they and their physician have control over their treatment plan.
This focus on meds has been going on for years. I work in the field and psychiatry appointments typically last 15 mins - who knows what they bill for. They throw meds at people that sometimes help. What burns me is when they don't many still try to keep people on them. You have to fight them to get off the meds.
Another problem with psychiatry is that anything gets labeled a mental disorder. Nobody gets left alone anymore, they have to be classified as mentally ill. Nobody is allowed to deal with their own problems without the "help" of doctors and drugs anymore. It's rediculous. I've heard of kids who refuse to do what they're told that were labeled with "oppositional defiance disorder". I heard a story about a girl who was labeled obsessive compulsive, because she does chores around her house, and helps clean up. And if a kid is bored in class, not paying attention, or fidgeting(all kids fidget, get used to it), or doing something other than their assignment, they get labeled with ADHD, or ADD. And it's not just a couple of kids, either. There are far too many VERY YOUNG KIDS WITH STILL DEVELOPING BODIES AND BRAINS, BEING PUT ON DANGEROUS MEDICATIONS. Some of which they probably don't even need. And the parents are being threatened with the possibility of losing custody of their child if they refuse to have them drugged up. Seriously, it's gotten out of hand, and doctors need to mind their own business about these sort of things, unless the patient brings it up, or decides ON THEIR OWN comes to the doctor about it.
To "Chris"
Some of your information is correct; however, your claim that SSRI's are addictive is completely unsubstatiated and false. Here is what WebMD has to say about SSRI addiction:
SSRIs do not cause addiction in the way cocaine, tobacco, or heroin do. After a period of exposure to SSRIs, however, the brain does adapt and get "used to" the medicine. For this reason, you shouldn't stop taking an SSRI suddenly without talking to your doctor. After completing treatment, the SSRI dose is tapered and stopped, and the brain readjusts.
Can patients who taper off SSRIs lapse back into depression? Yes, but that's not evidence of an addictive effect, it's evidence that the drug works. Let's stick to the facts, shall we?